Provider Demographics
NPI:1740263375
Name:DAHL, PEDER M (PT)
Entity type:Individual
Prefix:
First Name:PEDER
Middle Name:M
Last Name:DAHL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5777 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4502
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:5777 E MAYO BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-4502
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00007255OtherRAILROAD MEDICARE
AZ747751Medicaid
AZ747751Medicaid
AZP00007255OtherRAILROAD MEDICARE